{% extends "base.html" %}  
{% block title %} 患者列表 {% endblock %}  

{% block content %} 

  <div class="container">

    <!-- Docs nav
    ================================================== -->
    <div class="row">
      <div class="span3 bs-docs-sidebar">
        <ul class="nav nav-list bs-docs-sidenav">
        <li><a href="{% url sle.views.list_follow id %}"><i class="icon-chevron-right"></i> 返回列表</a></li>
        <li><a href="#pfxt"><i class="icon-chevron-right"></i>评分系统</a></li>
        <li><a href="#fzjc"><i class="icon-chevron-right"></i>辅助检查</a></li>     
        </ul>
      </div>
      
      

<div class="span9">
             
                         
              
              
               <section id="pfxt">
          <div class="page-header">
            <h2>评分系统</h2>
          </div>

        
<div class="bs-docs-example">

  <form id="pfxt_form" action="{% url sle.views.save_follow id %}" method="POST" class="form-inline" >{% csrf_token %}
     <div class="row-fluid show-grid">
   <div class="span6">
  <label class="control-label" for="ssddi">SSDDI</label>
  <input name="ssddi" id="ssddi" type="text" class="input-small" placeholder="SSDDI" readonly="readonly" />
  <a href="#myModal2" role="button" class="btn btn-mini btn-primary" data-toggle="modal">计算</a>
  </div>
  <div class="span6">
  <label class="control-label" for="ssdi">SSDI </label>
  <input name="ssdi" id="ssdi" type="text" class="input-small" placeholder="SSDI" readonly="readonly"/>
  <a href="#myModal1" role="button" class="btn btn-mini btn-primary" data-toggle="modal">计算</a>
  </div>
  </div>
  
  <div class="row-fluid show-grid">
  <div class="span6">
  <label class="control-label" for="essdai">ESSDAI</label>
  <input name="essdai" id="essdai" type="text" class="input-small" placeholder="ESSDAI"  readonly="readonly"/>
  <a href="#myModal" role="button" class="btn btn-mini btn-primary" data-toggle="modal">计算</a>
  </div>
  <div class="span6">
  <label class="control-label" for="esspri">ESSPRI</label>
  <input name="esspri" id="esspri" type="text" class="input-small" placeholder="ESSPRI"  />
  </div>
  </div>
  
  <div class="row-fluid show-grid">
  <div class="span6">
  <label class="control-label" for="PCS">sf-12/PCS</label>
  <input name="PCS" type="text" class="input-small" id="PCS" placeholder="sf-12/PCS"  />
  </div>
  <div class="span6">
    <label class="control-label" for="MCS">sf-12/MCS</label>
  <input name="MCS" type="text" class="input-small" id="MCS" placeholder="sf-12/MCS"  />
  </div>
  </div>
  
  <div class="row-fluid show-grid">
  <div class="span6">
      <label class="control-label" for="pcm">中医诊断</label>
  <input name="pcm" type="text" class="input-small" id="pcm" placeholder="中医诊断" />
  </div>
   <div class="span6">
        <label class="control-label" for="tongue">舌诊/脉诊</label>
  <input name="tongue" type="text" class="input-small" id="tongue" placeholder="舌诊/脉诊"  />
  </div>
  </div>
  
  <div class="row-fluid show-grid">
  <div class="span6">
        <label class="control-label" for="other">其它</label>
  <input name="other" type="text" class="input-small" id="other" placeholder="其它"  />
  </div>
   <div class="span6">
          <label class="control-label" for="inputdate_sf">随访日期</label>
  <input name="inputdate" type="text" class="input-small" id="inputdate_sf" placeholder="随访日期" onFocus="HS_setDate(this)" />
  </div>
  </div>
  
<br/>
  <button id="pfxt_submit" type="submit" class="btn btn-info" style="float:right;">保存</button>
</form>

</div>


        
        </section>
              
              
              
              
              
              
              <section id="fzjc">
          <div class="page-header">
            <h2>辅助检查</h2>
          </div>

        
<div class="bs-docs-example">

  <form id="fzjc_form" action="{% url sle.views.save_labfindings %}" method="POST" class="form-inline" >{% csrf_token %}<input type="hidden" value="{{id}}" name="patient_id"/>
  <div class="row-fluid show-grid">
   <div class="span6">
  <label class="control-label" for="Infection">ANA</label>
  <input name="ANA" id="ANA" type="text" class="input-small" placeholder="ANA" value=""/>
  </div>
  <div class="span6">
  <label class="control-label" for="Pregnancy">anti-ENA-Ab: Sm </label>
  <input name="anti_ENA_Ab" id="anti_ENA_Ab" type="text" class="input-small" placeholder="anti-ENA-Ab: Sm" value=""/>
  </div>
 </div>
 <div class="row-fluid show-grid">
   <div class="span6">
  <label class="control-label" for="Drugs">SSA/Ro </label>
  <input name="SSA" id="SSA" type="text" class="input-small" placeholder="SSA/Ro"  value=""/>
 </div>
 <div class="span6">
  <label class="control-label" for="Tired">SSB/La </label>
  <input name="SSB" type="text" class="input-small" id="SSB" placeholder="SSB/La"  value=""/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span6">
    <label class="control-label" for="Menopause"> RNP</label>
  <input name="RNP" type="text" class="input-small" id="RNP" placeholder=" RNP"  value=""/>
  </div>
  <div class="span6">
      <label class="control-label" for="Others">Jo-1</label>
  <input name="Jo" type="text" class="input-small" id="Jo" placeholder="Jo-1"  value=""/>
  </div>
  </div>
   <div class="row-fluid show-grid">
   <div class="span6">
        <label class="control-label" for="Fitment">Scl-70</label>
  <input name="Scl" type="text" class="input-small" id="Scl" placeholder="Scl-70"  value=""/>
  </div>
  <div class="span6">
        <label class="control-label" for="Psychogenic">dsDNA-Ab</label>
  <input name="dsDNA" type="text" class="input-small" id="dsDNA" placeholder="dsDNA-Ab"  value=""/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span6">
          <label class="control-label" for="Psychogenic">MPO- ANCA</label>
  <input name="MPO" type="text" class="input-small" id="MPO" placeholder="dsDNA-Ab"  value=""/>
  </div>
  <div class="span6">
          <label class="control-label" for="Fitment">PR3-ANCA</label>
  <input name="PR3" type="text" class="input-small" id="PR3" placeholder="PR3-ANCA"  value=""/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span6">
        <label class="control-label" for="Psychogenic">anti-CCP-Ab</label>
  <input name="anti_CCP_Ab" type="text" class="input-small" id="anti_CCP_Ab" placeholder="anti-CCP-Ab"  value=""/>
  </div>
  <div class="span6">
          <label class="control-label" for="Psychogenic">anticardiolipin antibody</label>
  <input name="anticardiolipin" type="text" class="input-small" id="anticardiolipin" placeholder="anticardiolipin antibody"  value=""/></div>
  </div>
   <div class="row-fluid show-grid">
   <div class="span6">
  <label class="control-label" for="Fitment">RF</label>
  <input name="RF" type="text" class="input-small" id="RF" placeholder="RF"  value=""/>
  </div>
  <div class="span6">
        <label class="control-label" for="Psychogenic"> serum IgG</label>
  <input name="serum" type="text" class="input-small" id="serum" placeholder=" g/L"  value=""/>
  </div>
  </div>
   <div class="row-fluid show-grid">
   <div class="span6">
          <label class="control-label" for="Psychogenic">IgM</label>
  <input name="IgM" type="text" class="input-small" id="IgM" placeholder=" g/L"  value=""/>
  </div>
  <div class="span6">
    <label class="control-label" for="Fitment">IgA</label>
  <input name="IgA" type="text" class="input-small" id="IgA" placeholder=" g/L"  value=""/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span6">
        <label class="control-label" for="Psychogenic">C3</label>
  <input name="C3" type="text" class="input-small" id="C3" placeholder=" g/L"  value=""/>
  </div>
  <div class="span6">
          <label class="control-label" for="Psychogenic">C4</label>
  <input name="C4" type="text" class="input-small" id="C4" placeholder=" g/L"  value=""/>
  </div>
  </div>
   <div class="row-fluid show-grid">
   <div class="span6">
      <label class="control-label" for="Fitment">CH50</label>
  <input name="CH50" type="text" class="input-small" id="CH50" placeholder="CH50"  value=""/>
  </div>
   <div class="span6">
        
  <label class="control-label" for="Psychogenic">糖皮质激素</label>
  <input name="hormone" type="text" class="input-small" id="hormone" placeholder="糖皮质激素"  value=""/>
  </div>
  </div>
   <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="Psychogenic">曾服用过的治疗SS药物、用法、疗程及起止时间</label>
  <input name="SS" type="text" class="input-small" id="SS" placeholder="曾服用过的治疗SS药物、用法、疗程及起止时间"  style="width:400px;"/>
  </div>
  </div>
   <div class="row-fluid show-grid">
   <div class="span12">
        <label class="control-label" for="Fitment">CTX</label>
  <input name="CTX" type="text" class="input-small" id="CTX" placeholder="CTX"   style="width:600px;">
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span12">
        <label class="control-label" for="Psychogenic">MTX</label>
  <input name="MTX" type="text" class="input-small" id="MTX" placeholder="MTX"   style="width:600px;"/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="Psychogenic">Aza</label>
  <input name="Aza" type="text" class="input-small" id="Aza" placeholder="Aza"   style="width:600px;"/>
  </div></div>
 <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="CQ">CQ/HCQ</label>
  <input name="CQ" type="text" class="input-small" id="CQ" placeholder="CQ/HCQ"   style="width:600px;"/>
  </div>
  </div>
 <div class="row-fluid show-grid">
   <div class="span12">
        <label class="control-label" for="reaction">反应停</label>
  <input name="reaction" type="text" class="input-small" id="reaction" placeholder="反应停"   style="width:600px;"/>
  </div></div>
  <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="X_ray">X-ray Film</label>
  <input name="X_ray" type="text" class="input-small" id="X_ray" placeholder="X-ray Film"   style="width:600px;"/>
  </div>
  </div>
 <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="CTScan">CT Scan</label>
  <input name="CTScan" type="text" class="input-small" id="CTScan" placeholder="CT Scan"   style="width:600px;"/>
  </div></div>
  <div class="row-fluid show-grid">
   <div class="span12">
        <label class="control-label" for="ECG">ECG </label>
  <input name="ECG" type="text" class="input-small" id="ECG" placeholder="ECG"  style="width:600px;"/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="Psychogenic">UCG</label>
  <input name="UCG" type="text" class="input-small" id="UCG" placeholder="UCG"   style="width:600px;"/>
  </div></div>
  <div class="row-fluid show-grid">
   <div class="span12">
            <label class="control-label" for="Fitment">Pulmonary Function Test</label>
  <input name="Pulmonary" type="text" class="input-small" id="Pulmonary" placeholder="Pulmonary Function Test"   style="width:500px;"/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span12">
        <label class="control-label" for="Psychogenic">EEG </label>
  <input name="EEG" type="text" class="input-small" id="EEG" placeholder="EEG"  style="width:600px;"/>
  </div></div>
 <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="Psychogenic">ultrasonagraphy</label>
  <input name="ultrasonagraphy" type="text" class="input-small" id="ultrasonagraphy" placeholder=""   style="width:600px;"/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span12">
              <label class="control-label" for="Fitment">EMG</label>
  <input name="EMG" type="text" class="input-small" id="EMG" placeholder="EMG"   style="width:600px;"/>
  </div></div>
  <div class="row-fluid show-grid">
   <div class="span12">
        <label class="control-label" for="Psychogenic">Labial Biopsy </label>
  <input name="Labial" type="text" class="input-small" id="Labial" placeholder="Labial Biopsy"  value=""/>
  <label class="control-label" for="Psychogenic">pathology NO.</label>
  <input name="pathologyNO1" type="text" class="input-small" id="pathologyNO1" placeholder=""  value=""/>
  <label class="control-label" for="date1">date</label>
  <input name="date1" type="text" class="input-small" id="date1" onFocus="HS_setDate(this)" placeholder=""  value=""/>
  </div>
  </div>
  <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="Psychogenic">Renal Biopsy </label>
  <input name="Renal" type="text" class="input-small" id="Renal" placeholder="Renal Biopsy"  value=""/>
  <label class="control-label" for="pathologyNO2">pathology NO.</label>
  <input name="pathologyNO2" type="text" class="input-small" id="pathologyNO2" placeholder=""  value=""/>
  <label class="control-label" for="date2">date</label>
  <input name="date2" type="text" class="input-small" id="date2" onFocus="HS_setDate(this)" placeholder=""  value=""/>
  </div></div>
            <div class="row-fluid show-grid">
   <div class="span12">
          <label class="control-label" for="Bone">Bone Marrow Biopsy </label>
  <input name="Bone" type="text" class="input-small" id="Bone" placeholder="Bone Marrow Biopsy"  value=""/>
          <label class="control-label" for="pathologyNO3">pathology NO.</label>
  <input name="pathologyNO3" type="text" class="input-small" id="pathologyNO3" placeholder=""  value=""/>
            <label class="control-label" for="date3">date</label>
  <input name="date3" type="text" class="input-small" id="date3" onFocus="HS_setDate(this)" placeholder=""  value=""/>
  </div></div>
   <div class="row-fluid show-grid">
   <div class="span6">
  <label class="control-label" for="Psychogenic">其他</label>
  <input name="other" type="text" class="input-small" id="other" placeholder="其他"  value=""/>
  </div>
  <div class="span6">
    <label class="control-label" for="Psychogenic">检查日期</label>
  <input name="inputdate" type="text" class="input-small" id="inputdate" placeholder="检查日期" onFocus="HS_setDate(this)" value=""/>
  </div>
  </div>
<br/>
  <button id="fzjc_submit" type="submit" class="btn btn-info" style="float:right;" disabled="disabled" >保存</button>
</form>

</div>


        
        </section>
       
</div>

</div>
</div>
















<!-- essdai 开始--><!-- essdai 开始--><!-- essdai 开始--><!-- essdai 开始--><!-- essdai 开始-->


<div id="myModal" class="modal hide fade" tabindex="-1" role="dialog" aria-labelledby="myModalLabel" aria-hidden="true">

<form action="{% url sle.views.save_essdai %}" method="post" id="essdai_form" />{% csrf_token %}
            <div class="modal-header">
              <button type="button" class="close" data-dismiss="modal" aria-hidden="true">&times;</button>
              <h3 id="myModalLabel">ESSDAI</h3>
            </div>
            <div class="modal-body">

              <table class="table table-bordered">
  <caption>
    Constitutional domain [3]<br/>
    请注意不要计入与本病无关的一些全身症状 (例如感染性发热、主动减肥)
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;无以下症状</td>
    <td>
        <input type="radio" name="RadioGroup1" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;轻微发热或间断发热 (37.5°-38.5°C) / 夜间盗汗/体重下降5~10%</td>
    <td>
        <input type="radio" name="RadioGroup1" value="3" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;明显发热 (>38.5°C) /夜间盗汗/体重下降>10%</td>
    <td>
        <input type="radio" name="RadioGroup1" value="6" id="RadioGroup1_2" />   
    </td>
  </tr>

</table>

 <table class="table table-bordered">
  <caption>
    Lymphadenopathy domain [4]
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;无以下症状</td>
    <td>
        <input type="radio" name="RadioGroup2" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;- 任何淋巴结区域淋巴结 ≥ 1cm / 腹股沟淋巴结 ≥ 2cm</td>
    <td>
        <input type="radio" name="RadioGroup2" value="4" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;-任何淋巴结区域淋巴结 ≥ 2cm  / 腹股沟淋巴结≥ 3cm,  和/或 脾脏肿大 (临床触及或影像学证实)
</td>
    <td>
        <input type="radio" name="RadioGroup2" value="8" id="RadioGroup1_2" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;存在恶性B-细胞增殖
</td>
    <td>
        <input type="radio" name="RadioGroup2" value="12" id="RadioGroup1_3" />   
    </td>
  </tr>



</table>


 <table class="table table-bordered">
  <caption>
Glandular  domain [2]<br/>
请注意不要计入与本病无关的一些腺体肿大症状(例如结石或感染) 
主动减肥)
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;无腺体肿大</td>
    <td>
        <input type="radio" name="RadioGroup3" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;轻度腺体肿大:<br/>
-	腮腺肿大 (≤ 3cm), <br/>
-	或 局限性颌下腺 / 泪腺肿大1&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</td>
    <td>
        <input type="radio" name="RadioGroup3" value="2" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;重度腺体肿大:<br/>
-	腮腺肿大 (>3cm )<br/>
-	或 广泛性颌下腺 / 泪腺肿大1
</td>
    <td>
        <input type="radio" name="RadioGroup3" value="4" id="RadioGroup1_2" />   
    </td>
  </tr>

</table>



 <table class="table table-bordered">
  <caption>
Articular domain [2]<br/>
请注意不要计入与本病无关的一些关节累及症状(例如骨性关节炎)
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;目前无活动性关节受累</td>
    <td>
        <input type="radio" name="RadioGroup4" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;手、腕、踝及足关节痛 伴晨僵 (>30 min)
</td>
    <td>
        <input type="radio" name="RadioGroup4" value="2" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;1到5个关节存在滑膜炎（28个关节中） 
</td>
    <td>
        <input type="radio" name="RadioGroup4" value="4" id="RadioGroup1_2" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;≥ 6个关节存在滑膜炎（28个关节中）&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</td>
    <td>
        <input type="radio" name="RadioGroup4" value="6" id="RadioGroup1_3" />   
    </td>
  </tr>


</table>


 <table class="table table-bordered">
  <caption>
Cutaneous domain [3]<br/>
由疾病损害非病情活动所致的持续稳定存在的症状以及与本病无关的皮肤症状应计为“无活动”

  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;目前无活动性皮肤受累</td>
    <td>
        <input type="radio" name="RadioGroup5" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;多形红斑
</td>
    <td>
        <input type="radio" name="RadioGroup5" value="3" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;局限性皮肤血管炎, 包括荨麻疹性血管炎2 或足及踝部紫癜或亚急性皮肤狼疮
</td>
    <td>
        <input type="radio" name="RadioGroup5" value="6" id="RadioGroup1_2" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;弥漫性皮肤血管炎, 包括荨麻疹性血管炎2或 弥漫性紫癜或血管炎相关的溃疡
</td>
    <td>
        <input type="radio" name="RadioGroup5" value="9" id="RadioGroup1_3" />   
    </td>
  </tr>


</table>


 <table class="table table-bordered">
  <caption>
Pulmonary domain [5]<br/>
由疾病损害非病情活动所致的持续稳定存在的症状以及与本病无关的呼吸系统累及(例如吸烟等)应计为“无活动”
为“无活动”
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;目前无活动性肺部累及</td>
    <td>
        <input type="radio" name="RadioGroup6" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;持续性咳嗽或支气管病变，但X线摄片无异常表现；<br/>
或者放射学/HRCT 证实间质性肺病3 ：<br/>
•	无呼吸困难，<br/>
•	并且肺功能正常。

</td>
    <td>
        <input type="radio" name="RadioGroup6" value="5" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;中度活动性肺部病变，例如HRCT3证实间质性肺病<br/>
•	活动后气促 (NHYA II) <br/>
•	或 肺功能异常，表现为：<br/>
-	70% >DLCO ≥ 40% and/or 80% > FVC ≥ 60%

</td>
    <td>
        <input type="radio" name="RadioGroup6" value="10" id="RadioGroup1_2" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;高度活动性肺部病变，例如HRCT3证实间质性肺病：<br/>
•	休息时气促  (NHYA III, IV)<br/>
•	或 肺功能异常，表现为：<br/>
-	DLCO < 40% and/or FVC < 60%

</td>
    <td>
        <input type="radio" name="RadioGroup6" value="15" id="RadioGroup1_3" />   
    </td>
  </tr>


</table>




 <table class="table table-bordered">
  <caption>
Renal domain [5]<br/>
由疾病损害非病情活动所致的持续稳定存在的症状以及与本病无关的肾脏累及应计为“无活动”
如果已行活检，请首先按组织学特征评估活动性。
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;目前无活动性肾脏病变：<br/>
-	蛋白尿< 0.5g/d，无血尿，无白细胞尿，无酸中毒。<br/>
-	或 由疾病损害导致的长时间持续稳定的蛋白尿
</td>
    <td>
        <input type="radio" name="RadioGroup7" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;特异性活动性肾脏病变证据，限于：<br/>
•	无肾衰的肾小管酸中毒 (GFR4 ≥60ml/min)<br/>
•	肾小球病变 <br/>
-	蛋白尿 ( 0.5~1 g/d) <br/>
-	无血尿或肾衰 (GFR4 ≥60ml/min)


</td>
    <td>
        <input type="radio" name="RadioGroup7" value="5" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;中度活动性肾脏病变，例如：<br/>
•	伴肾衰的肾小管酸中毒 (GFR4 < 60 ml/min)<br/>
•	肾小球病变 <br/>
-	  蛋白尿 (1~1.5 g/d)  <br/>
-	  无血尿或肾衰 (GFR4 ≥ 60ml/min)<br/>
•	或 组织学证据 <br/>
-	 膜外肾小球肾炎<br/>
-	 重度间质淋巴细胞浸润


</td>
    <td>
        <input type="radio" name="RadioGroup7" value="10" id="RadioGroup1_2" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;高度活动性肾脏病变，例如：<br/>
•	肾小球病变 <br/>
-	蛋白尿 > 1.5 g/d<br/>
-	或 血尿 <br/>
-	或 肾衰 (GFR4 < 60 ml/min)<br/>
•	 组织学证据 <br/>
-	增生性肾小球肾炎<br/>
-	冷球蛋白血症相关性肾脏病变 


</td>
    <td>
        <input type="radio" name="RadioGroup7" value="15" id="RadioGroup1_3" />   
    </td>
  </tr>


</table>



 <table class="table table-bordered">
  <caption>
Muscular domain [6]<br/>
由疾病损害非病情活动所致的持续稳定存在的症状以及与本病无关的肌肉累及（皮质类固醇引起的肌无力）应计为“无活动”
动性。
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;目前无活动性肌肉病变
</td>
    <td>
        <input type="radio" name="RadioGroup8" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;异常肌电图或活检证实的低度活动性肌炎：<br/>
-	无肌无力 <br/>
-	并且 肌酸激酶轻度升高(N < CK ≤ 2N)
</td>
    <td>
        <input type="radio" name="RadioGroup8" value="6" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;异常肌电图或活检证实的中度活动性肌炎：<br/>
-	肌无力 (≥ 4/5),<br/>
-	或 肌酸激酶中度升高 (2N < CK ≤ 4N), 
</td>
    <td>
        <input type="radio" name="RadioGroup8" value="12" id="RadioGroup1_2" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;异常肌电图或活检证实的高度活动性肌炎：<br/>
-	肌无力 (deficit ≤ 3/5)<br/>
-	或 肌酸激酶重度升高  (> 4N)

</td>
    <td>
        <input type="radio" name="RadioGroup8" value="18" id="RadioGroup1_3" />   
    </td>
  </tr>


</table>


 <table class="table table-bordered">
  <caption>
Peripheral nervous system domain [5]<br/>
由疾病损害非病情活动所致的持续稳定存在的症状以及与本病无关的周围神经系统累及应计为“无活动”
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;目前无活动性周围神经病变
</td>
    <td>
        <input type="radio" name="RadioGroup9" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;活动性周围神经系统病变证据，例如：<br/>
-	- 神经传导检查证实的单纯感觉轴突多神经病变<br/>
-	-三叉神经痛(V) 
</td>
    <td>
        <input type="radio" name="RadioGroup9" value="5" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;通过神经传导检查呈现的中度活动性周围神经系统病变证据，例如：<br/>
-	伴运动缺陷的轴突感觉运动神经病 ≤  4/5, <br/>
-	伴冷球蛋白性血管炎的单纯性感觉神经病,<br/>
-	神经节病变导致的轻中度共济失调5, <br/>
-	出现中度功能性损害的慢性炎症性脱髓鞘性多发性神经病6 (CIDP) (运动缺陷 ≤ 4/5 或 中度共济失调),
或者周围性颅神经累及 (三叉神经痛(V) 除外)
</td>
    <td>
        <input type="radio" name="RadioGroup9" value="10" id="RadioGroup1_2" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;神经传导检查证实的高活动性周围神经系统累及的证据，例如： <br/>
-	伴运动缺陷的轴突感觉运动神经病 ≤ 3/5<br/>
-	血管炎导致的周围神经累及 (多发性单神经炎，等等…)<br/>
-	神经节病变导致的严重共济失调5 <br/>
-	伴有严重功能损害的慢性炎症性脱髓鞘性多发性神经病6 (CIDP): 运动缺陷 ≤ 3/5 或者严重共济失调
</td>
    <td>
        <input type="radio" name="RadioGroup9" value="15" id="RadioGroup1_3" />   
    </td>
  </tr>


</table>


<table class="table table-bordered">
  <caption>
Central nervous system domain [5]<br/>
由疾病损害非病情活动所致的持续稳定存在的症状以及与本病无关的中枢神经系统累及应计为“无活动”
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;目前无活动性中枢神经系统病变
</td>
    <td>
        <input type="radio" name="RadioGroup10" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;中活动度</td>
    <td>&nbsp;中度中枢神经系统特征，例如：<br/>
- 中枢性的脑神经病变<br/>
- 视神经炎<br/>
- 多发性硬化样综合征限于纯粹的感觉损害或证实认知损害 

</td>
    <td>
        <input type="radio" name="RadioGroup10" value="10" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;高度活动性中枢神经系统病变特征，例如：<br/> 
- 出现脑血管意外或短暂性脑缺血发作的脑血管炎 <br/>
- 发作<br/>
- 横贯性脊髓炎 <br/>
- 淋巴细胞性脑膜炎<br/>
- 出现运动缺陷的多发性硬化样综合征

</td>
    <td>
        <input type="radio" name="RadioGroup10" value="15" id="RadioGroup1_2" />   
    </td>
  </tr>


</table>



 <table class="table table-bordered">
  <caption>
Hematological  domain [2]<br/>
请注意：
- 对于贫血7、血小板减少症8 、中性粒细胞减少症9，仅自身免疫性血细胞减少才被考虑
- 与本病无关的血细胞减少不记(例如 维生素或铁缺乏,药物造成的血细胞减少，例如环磷酰胺相关的淋巴细胞减少症)
为“无活动”
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;无自身免疫性血细胞减少
</td>
    <td>
        <input type="radio" name="RadioGroup11" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;自身免疫性血细胞减少：<br/>
- 中性粒细胞减少症 (1000 <  中性粒细胞 < 1500/mm3)<br/>
- 或 贫血 (10 < 血红蛋白 < 12g/dl)<br/>
- 或 血小板减少症 ( 100,000 < 血小板 < 150,000/mm3) <br/>
或 淋巴细胞减少症 (500< 淋巴细胞 <1000/mm3)

</td>
    <td>
        <input type="radio" name="RadioGroup11" value="2" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp;自身免疫性血细胞减少：<br/>
-中性粒细胞减少症(500 ≤ 中性粒细胞 ≤  1000/mm3),<br/>
-或 贫血(8 ≤ 血红蛋白  ≤ 10g/dl) <br/>
-或 血小板减少症(50,000 ≤ 血小板 ≤ 100,000/mm3) <br/>
或 淋巴细胞减少症(≤ 500/mm3)
</td>
    <td>
        <input type="radio" name="RadioGroup11" value="4" id="RadioGroup1_2" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;高活动度</td>
    <td>&nbsp;自身免疫性血细胞减少：<br/>
-中性粒细胞减少症(中性粒细胞 < 500/mm3),<br/>
-或 贫血(血红蛋白 < 8 g/dl) <br/>
-或 血小板减少症(血小板 < 50,000/mm3), 

</td>
    <td>
        <input type="radio" name="RadioGroup11" value="6" id="RadioGroup1_3" />   
    </td>
  </tr>


</table>


 <table class="table table-bordered">
  <caption>
Biological domain [1]
  </caption>
  <tr>
    <td width="80px">&nbsp;无活动</td>
    <td>&nbsp;无以下任何生物学特征
</td>
    <td>
        <input type="radio" name="RadioGroup12" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;低活动度</td>
    <td>&nbsp;- 血清中出现同源细胞克隆成分 <br/>
- 或 低补体血症 (low C4 or C3 or CH50) <br/>
- 或 高丙种球蛋白血症 或 IgG 水平介于 16 ~ 20g/L


</td>
    <td>
        <input type="radio" name="RadioGroup12" value="1" id="RadioGroup1_1" />   
    </td>
  </tr>
  <tr>
     <td>&nbsp;中活动度</td>
    <td>&nbsp; - 出现冷球蛋白血症 <br/>
- 或 高丙种球蛋白血症 或 IgG 水平 > 20g/L<br/>
-或 近期发生的10低丙种球蛋白血症 或IgG水平近期下降 (<5g/L)
</td>
    <td>
        <input type="radio" name="RadioGroup12" value="2" id="RadioGroup1_2" />   
    </td>
  </tr>
 


</table>




              
            </div>
            
            <div class="modal-footer">
              <button class="btn" data-dismiss="modal">关闭</button>
              <button class="btn btn-primary" type="submit">保存</button>
            </div>
            </form>
          </div>



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<div id="myModal1" class="modal hide fade" tabindex="-1" role="dialog" aria-labelledby="myModalLabel" aria-hidden="true">

<form action="{% url sle.views.save_ssdi %}" method="post" id="ssdi_form" />{% csrf_token %}
            <div class="modal-header">
              <button type="button" class="close" data-dismiss="modal" aria-hidden="true">&times;</button>
              <h3 id="myModalLabel">SSDI</h3>
            </div>
            <div class="modal-body">

              <table class="table table-bordered">
  <caption>
眼睛
  </caption>
  <tr>
    <td>&nbsp;1. 角膜瘢痕形成*</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup1" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup1" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td>&nbsp;2. 不可逆性Schirmer试验低值 （<5mm/5min）。<br/>
（如果首次评估时< 5mm/5min ，2周内需重复测量） 
</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup2" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup2" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;3. 泪小管手术 (曾经接受)</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup3" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup3" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;SSDDI only:	4. 慢性睑炎* </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup4" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup4" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;SSDDI only:	5. 曾患任何类型的白内障*	 </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup5" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup5" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>

</table>



              <table class="table table-bordered">
  <caption>
口腔
  </caption>
  <tr>
    <td>&nbsp;6. 不可逆性的低唾液流率 (USF <1.5ml/15min) <br/> （如果首次评估时USF <1.5ml/15min，2周内需重复测量）</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup6" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup6" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td>&nbsp;7. 严重的龋齿
</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup7" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup7" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;8. 牙齿缺失*	</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup8" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup8" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;9. 唾液腺肿大	 </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup9" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup9" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>

</table>



   <table class="table table-bordered">
  <caption>

  </caption>
  <tr>
    <td>&nbsp;Schirmer 1 test (abn< 5mm/5min)*<br/>
    10.R&nbsp;<input type="text" id="text_r" name="text_r" value=""/>
    11.L&nbsp;<input type="text" id="text_l" name="text_l" value=""/></td>
   </tr>
   <tr>
    <td>&nbsp;12. 非刺激性唾液流率 (abn < 1.5 mls/15 mins)*
        <input type="text" id="text_12" name="text_12" value=""/>mls/ 15 mins
    </td>
    
  </tr>

</table>


              <table class="table table-bordered">
  <caption>
神经精神病变   
  </caption>
  <tr>
    <td>&nbsp;13. 颅神经病变*</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup10" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup10" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td>&nbsp;14. 周围神经病变*
</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup11" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup11" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;15. 多发性单神经炎*	</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup12" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup12" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;16. 其他中枢神经系统累及* 	 </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup13" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup13" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>

</table>


 <table class="table table-bordered">
  <caption>
肾脏   
  </caption>
  <tr>
    <td>&nbsp;17. 肾小球滤过率GFR<50%</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup14" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup14" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td>&nbsp;18. 蛋白尿 > 3.5g/24h
</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup15" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup15" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;19. 肾小管性酸中毒* </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup16" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup16" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;(需要治疗) </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup20" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup20" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;20. 肾钙质沉着症* </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup17" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup17" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;21. 终末期 (不论是否透析或肾移植)  </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup18" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup18" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;SSDDI: 22. 血清肌酐升高或GFR下降* </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup19" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup19" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>

</table>


 <table class="table table-bordered">
  <caption>
肺  
  </caption>
  <tr>
    <td>&nbsp;23. 胸膜纤维化（放射显影图）*</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup21" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup21" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td>&nbsp;24. 肺动脉高压	
</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup22" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup22" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;25. 肺纤维化（放射显影图）*	</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup23" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup23" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;SSDDI: 26. 肺功能检查证实显著的不可逆性肺功能损害</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup24" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup24" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;SSDDI: 27. 心肌病（心室功能障碍） </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup25" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup25" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>

</table>


 <table class="table table-bordered">
  <caption>
胃肠肝胆  
  </caption>
  <tr>
    <td>&nbsp;28. 慢性胰腺炎</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup26" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup26" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td>&nbsp;29. 原发性胆汁性肝硬变（PBC） 
</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup27" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup27" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;30. 腹部疾病	</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup28" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup28" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;31. 需要治疗的甲状腺衰竭	</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup29" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup29" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
</table>


 <table class="table table-bordered">
  <caption>
肌肉骨骼  
  </caption>
  <tr>
    <td>&nbsp;32. 致畸性或侵蚀性关节炎 </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup30" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup30" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td>&nbsp; 33. 骨质疏松  
</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup31" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup31" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;34. 骨关节炎	</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup32" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup32" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;35. 缺血性坏死 </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup33" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup33" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
</table>


 <table class="table table-bordered">
  <caption>
恶性病变  
  </caption>
  <tr>
    <td>&nbsp;36. 副蛋白 </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup34" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup34" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td>&nbsp;37. 巨球蛋白血症*
</td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup35" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup35" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
    <tr>
    <td>&nbsp;38. 冷球蛋白血症   </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup36" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup36" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;39. 骨髓瘤* </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup37" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup37" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;40. 淋巴瘤* </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup38" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup38" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
  <tr>
    <td>&nbsp;41. 其他恶性病变	 </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup39" value="0" id="RadioGroup1_0"  checked="checked" />   
    </td>
    <td>&nbsp;1&nbsp;
        <input type="radio" name="RadioGroup39" value="1" id="RadioGroup1_1"  />   
    </td>
  </tr>
</table>


<table class="table table-bordered">
  <caption>
附加血液检测结果:  
  </caption>
  <tr>
    <td>&nbsp; 类风湿因子阳性 </td>
   
    <td>&nbsp;0&nbsp;
        <input type="radio" name="RadioGroup40" value="0" id="RadioGroup1_0"  checked="checked" />
    </td>
    <td>&nbsp;1&nbsp;
       <input type="radio" name="RadioGroup40" value="1" id="RadioGroup1_1"  />
    </td>
  </tr>
  <tr>
    <td colspan="3">&nbsp;滴度:<input type="text" name="dd" id="dd" value=""/>
   
    &nbsp;(正常参考范围<input type="text" name="zcfw_dd" id="zcfw_dd" value=""/>) 
    
    &nbsp;&nbsp;
    </td>
  </tr>
    <tr>
    <td colspan="3">&nbsp;甲状腺功能TFTs:T4 &nbsp;<input type="text" name="t4" id="t4" style="width:180px;" value=""/>
   
    &nbsp;正常参考范围&nbsp;
        <input type="text" name="zcfw_t4" id="zcfw_t4" style="width:180px;" value=""/><br/>
    
    &nbsp;TSH&nbsp;<input type="text" value="" name="tsh" id="tsh" style="width:180px;"/>
    正常参考范围&nbsp;<input type="text" value="" name="zcfw_tsh" id="zcfw_tsh"  style="width:180px;"/>		
    </td>
  </tr>

</table>
       
            </div>
            
            <div class="modal-footer">
              <button class="btn" data-dismiss="modal">关闭</button>
              <button class="btn btn-primary" type="submit">保存</button>
            </div>
            </form>
          </div>



<!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束-->
<!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束--><!-- ssdi 结束-->



<!-- essdai 开始--><!-- essdai 开始--><!-- essdai 开始--><!-- essdai 开始--><!-- essdai 开始-->


<div id="myModal2" class="modal hide fade" tabindex="-1" role="dialog" aria-labelledby="myModalLabel" aria-hidden="true">

<form action="{% url sle.views.save_ssddi %}" method="post" id="ssddi_form" />{% csrf_token %}
            <div class="modal-header">
              <button type="button" class="close" data-dismiss="modal" aria-hidden="true">&times;</button>
              <h3 id="myModalLabel">SSDDI</h3>
            </div>
            <div class="modal-body">

              <table class="table table-bordered">
  <caption>
口部/唾液分泌损害
  </caption>
  <tr>
    <td>&nbsp;唾液流量损害</td>
   
    <td>收集全部非刺激性唾液† ＜1.5毫升/15分钟
    </td>
    <td>&nbsp;
      <input id="checkbox1" name="checkbox1" type="checkbox" value="1" />
    </td>
  </tr>
  <tr>
    <td>&nbsp;牙齿脱落 
</td>
   
    <td>&nbsp;0&nbsp;全部或几乎全部牙齿脱落
    </td>
    <td>&nbsp;
        <input id="checkbox2" name="checkbox2" type="checkbox" value="1" />
    </td>
  </tr>
</table>


              <table class="table table-bordered">
  <caption>
眼睛损害
  </caption>
  <tr>
    <td>&nbsp;泪液流量损害</td>
   
    <td>&nbsp;Schirmer I 试验† ＜5 毫米（5分钟内）
    </td>
    <td>&nbsp;<input id="checkbox3" name="checkbox3"  type="checkbox" value="1"/>
    </td>
  </tr>
  <tr>
    <td>&nbsp;结构异常
</td>
   
    <td>&nbsp;角膜溃疡、白内障、慢性睑炎
    </td>
    <td>&nbsp;<input id="checkbox4" name="checkbox4"  type="checkbox" value="1" />
    </td>
  </tr>

</table>


    <table class="table table-bordered">
  <caption>
神经系统损害
  </caption>
  <tr>
    <td>&nbsp;中枢神经系统累及</td>
   
    <td>&nbsp;持续稳定的中枢神经系统累及
    </td>
    <td>&nbsp;<input id="checkbox5" name="checkbox5" type="checkbox" value="2" />
    </td>
  </tr>
  <tr>
    <td>&nbsp;周围神经病变
</td>
   
    <td>&nbsp;持续稳定的周围神经或自主神经系统损害
    </td>
    <td>&nbsp;<input id="checkbox6" name="checkbox6" type="checkbox" value="1" />
    </td>
  </tr>

</table>


    <table class="table table-bordered">
  <caption>
胸膜肺的损害 (满足以下任何条目)&nbsp;&nbsp;2&nbsp;分
  </caption>
  <tr>
    <td>&nbsp;胸膜纤维化</td>
   
    <td>&nbsp;影像学确认
    </td>
    <td>&nbsp;<input id="checkbox7" name="checkbox7" type="checkbox" value="1" />
    </td>
  </tr>
  <tr>
    <td>&nbsp;间质纤维化
</td>
   
    <td>&nbsp;影像学确认
    </td>
    <td>&nbsp;<input id="checkbox8" name="checkbox8" type="checkbox" value="1" />
    </td>
  </tr>
  <tr>
    <td>&nbsp;显著的不可逆肺功能损害
</td>
   
    <td>&nbsp;肺活量测定确认
    </td>
    <td>&nbsp;<input id="checkbox9" name="checkbox9" type="checkbox" value="1" />
    </td>
  </tr>

</table>


    <table class="table table-bordered">
  <caption>
肾脏损害(满足以下任何条目)&nbsp;&nbsp;2&nbsp;分
  </caption>
  <tr>
    <td>&nbsp;血清肌酐水平上升
或肾小球滤过率下降
</td>
   
    <td>&nbsp;持续稳定的异常
    </td>
    <td>&nbsp;<input id="checkbox10" name="checkbox10" type="checkbox" value="1" />
    </td>
  </tr>
  <tr>
    <td>&nbsp;肾小管酸中毒
</td>
   
    <td>&nbsp;两次连续监测尿pH值＞6 并且
血清碳酸氢根＜15毫摩尔/升

    </td>
    <td>&nbsp;<input id="checkbox11" name="checkbox11" type="checkbox" value="1" />
    </td>
  </tr>
  <tr>
    <td>&nbsp;肾钙质沉着症
</td>
   
    <td>&nbsp;影像学确认
    </td>
    <td>&nbsp;<input id="checkbox12" name="checkbox12" type="checkbox" value="1" />
    </td>
  </tr>

</table>


    <table class="table table-bordered">
  <caption>
淋巴组织增生性疾病
(满足以下任何条目)&nbsp;&nbsp;5&nbsp;分
  </caption>
  <tr>
    <td>&nbsp;B细胞淋巴瘤
</td>
   
    <td>&nbsp;临床和组织学确认
    </td>
    <td>&nbsp;<input id="checkbox13" name="checkbox13" type="checkbox" value="1" />
    </td>
  </tr>
  <tr>
    <td>&nbsp;多发性骨髓瘤
</td>
   
    <td>&nbsp;临床和组织学确认
    </td>
    <td>&nbsp;<input id="checkbox14" name="checkbox14" type="checkbox" value="1" />
    </td>
  </tr>
  <tr>
    <td>&nbsp;Waldenström’s 巨球蛋白血症
</td>
   
    <td>&nbsp;临床和组织学确认
    </td>
    <td>&nbsp;<input id="checkbox15" name="checkbox15" type="checkbox" value="1" />
    </td>
  </tr>

</table>




              
            </div>
            
            <div class="modal-footer">
              <button class="btn" data-dismiss="modal">关闭</button>
              <button class="btn btn-primary" type="submit">保存</button>
            </div>
            </form>
          </div>



<!-- ssddi 结束--><!-- ssddi 结束--><!-- ssddi 结束--><!-- ssddi 结束--><!-- ssddi 结束--><!-- ssddi 结束-->
<!-- ssddi 结束--><!-- ssddi 结束--><!-- ssddi 结束--><!-- ssddi 结束--><!-- ssddi 结束--><!-- ssddi 结束-->





{% endblock %} 

{% block some_js %}

<script type="text/javascript">





  
 
 $(document).ready(function() {
 
 
 $('#pfxt_form').validate({
 rules: {
			
			inputdate:{    
       						dateISO: true,
							required: true
							},
			
			
		},
		messages: {
			
			
			inputdate: "请输入正确的日期,如：2000-01-01",
			

		
		},
		
		
 
 });
 
 
  //提交开始
 $('#essdai_form').submit(function() {
		$('#showmessage').css("display","block");
		calc_essdai();
		$('#myModal').modal('hide');
		$.ajax({ // create an AJAX call...
                data: $(this).serialize(), // get the form data
                type: $(this).attr('method'), // GET or POST
                url: $(this).attr('action'), // the file to call
                success: function(response,textStatus) { // on success..
				$('#showmessage').text('信息已经更新!');
                 
				  setTimeout(function() {
				  $('#showmessage').css("display","none");
				  }, 1500);
              
                }
            });
            return false;

		});//提交结束 
 
 
 
 //提交开始
 $('#ssdi_form').submit(function() {
		$('#showmessage').css("display","block");
		$('#myModal1').modal('hide');
		$.ajax({ // create an AJAX call...
                data: $(this).serialize(), // get the form data
                type: $(this).attr('method'), // GET or POST
                url: $(this).attr('action'), // the file to call
                success: function(response,textStatus) { // on success..
				$('input[id=ssdi]').val($.evalJSON(response).total).focus();
				$('#showmessage').text('信息已经更新!');
                 
				  setTimeout(function() {
				  $('#showmessage').css("display","none");
				  }, 1500);
               
                }
            });
            return false;

		});//提交结束 
 
 //提交开始
 $('#ssddi_form').submit(function() {
		$('#showmessage').css("display","block");
		calc_ssddi();
		$('#myModal2').modal('hide');
		$.ajax({ // create an AJAX call...
                data: $(this).serialize(), // get the form data
                type: $(this).attr('method'), // GET or POST
                url: $(this).attr('action'), // the file to call
                success: function(response,textStatus) { // on success..
				$('#showmessage').text('信息已经更新!');
                  
				  setTimeout(function() {
				  $('#showmessage').css("display","none");
				  }, 1500);
               
                }
            });
            return false;

		});//提交结束 
 
 

 //提交开始
 $('#pfxt_form').submit(function() {
		$('#showmessage').css("display","block");
		$.ajax({ // create an AJAX call...
                data: $(this).serialize(), // get the form data
                type: $(this).attr('method'), // GET or POST
                url: $(this).attr('action'), // the file to call
                success: function(response,textStatus) { // on success..
				$('#showmessage').text('信息已经更新!');
                  $('#pfxt_submit').attr('disabled',"true");
				  $('#fzjc_submit').removeAttr("disabled");
				  setTimeout(function() {
				  $('#showmessage').css("display","none");
				  }, 1500);
               
                }
            });
            return false;

		});//提交结束 


 //提交开始
 $('#fzjc_form').submit(function() {
		$('#showmessage').css("display","block");
		$.ajax({ // create an AJAX call...
                data: $(this).serialize(), // get the form data
                type: $(this).attr('method'), // GET or POST
                url: $(this).attr('action'), // the file to call
                success: function(response,textStatus) { // on success..
				$('#showmessage').text('信息已经更新!');
                  window.location.href ="{% url sle.views.list_follow id %}";
				  setTimeout(function() {
				  $('#showmessage').css("display","none");
				  }, 1500);
               
                }
            });
            return false;
        
		
		
		});//提交结束  
 
 
     }); //onready end 
    
 

  
  var calc_essdai =function()
    {
	
	var v1 = $("input[name='RadioGroup1']:checked").val();
	var v2 = $("input[name='RadioGroup2']:checked").val();
	var v3 = $("input[name='RadioGroup3']:checked").val();
	var v4 = $("input[name='RadioGroup4']:checked").val();
	var v5 = $("input[name='RadioGroup5']:checked").val();
	var v6 = $("input[name='RadioGroup6']:checked").val();
	var v7 = $("input[name='RadioGroup7']:checked").val();
	var v8 = $("input[name='RadioGroup8']:checked").val();
	var v9 = $("input[name='RadioGroup9']:checked").val();
	var v10 = $("input[name='RadioGroup10']:checked").val();
	var v11 = $("input[name='RadioGroup11']:checked").val();
	var v12 = $("input[name='RadioGroup12']:checked").val();
    var total = parseInt(v1)+parseInt(v2)+parseInt(v3)+parseInt(v4)
	+parseInt(v5)+parseInt(v6)+parseInt(v7)+parseInt(v8)+parseInt(v9)
	+parseInt(v10)+parseInt(v11)+parseInt(v12);
	 $('input[id=essdai]').val(total).focus();
  }
  
  
  
  var calc_ssddi =function()
    {
	
	var v1 = 0;
	var v2 = 0;
	var v3 = 0;
	var v4 = 0;
	var v5 = 0;
	var v6 = 0;
	var v7 = 0;
	var v8 = 0;
	var v9 = 0;
	
	if($("input[name='checkbox1']").attr('checked')){
	v1 = $("input[name='checkbox1']").val();
	}
		if($("input[name='checkbox2']").attr('checked')){
	v2 = $("input[name='checkbox2']").val();

	}
		if($("input[name='checkbox3']").attr('checked')){
	v3 = $("input[name='checkbox3']").val();

	}
		if($("input[name='checkbox4']").attr('checked')){
	v4 = $("input[name='checkbox4']").val();

	}
		if($("input[name='checkbox5']").attr('checked')){
	v5 = $("input[name='checkbox5']").val();

	}
		if($("input[name='checkbox6']").attr('checked')){
	v6 = $("input[name='checkbox6']").val();

	}
	
	if( $("input[name='checkbox7']").attr('checked') || $("input[name='checkbox8']").attr('checked') || $("input[name='checkbox9']").attr('checked')  ){
	 v7 = 2;

	}
		if( $("input[name='checkbox10']").attr('checked') || $("input[name='checkbox11']").attr('checked') || $("input[name='checkbox12']").attr('checked')  ){
	 v8 = 2;

	}
			if( $("input[name='checkbox13']").attr('checked') || $("input[name='checkbox14']").attr('checked') || $("input[name='checkbox15']").attr('checked')  ){
	 v9 = 5;

	}
	
	
    var total = parseInt(v1)+parseInt(v2)+parseInt(v3)+parseInt(v4)
	+parseInt(v5)+parseInt(v6)+v7+v8+v9;
	 $('input[id=ssddi]').val(total).focus();
  }
  
 
  </script>

{% endblock %}